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In January 2009 Allen & Hanburys launched Avamys®T (fluticasone furoate), an intra-nasal 
steroid (INS) for treatment of the symptoms of allergic rhinitis. 1 Avamys (fluticasone furoate) is a different 
chemical entity to Flixonase® (fluticasone propionate) and is therefore a distinct drug molecule and not 
a salt or a prodrug of fluticasone propionate. 2 

A survey taken in May 2009, amongst 128 pharmacists showed that: 3 

• 31% were unaware of this INS (Avamys, fluticasone furoate). 

• 63% were not aware of the differences between fluticasone furoate and fluticasone propionate. 

Allen & Hanburys would like to highlight the important key differences that will support you in dispensing 

the right medicine. 


fluticasone propionate 4 ' 5 

Dose per spray 



Sprays per pack 



Licence Age 

6 years and older 

4 years and older 

Cost (on prescription) 



In a single dose study comparing Avamys to fluticasone propionate nasal spray, patients preferred 
Avamys over fluticasone propionate based on sensory attributes. 6 Avamys provides relief from both 
nasal and ocular symptoms in an advanced device. 710 Avamys is available to purchase from AAH and 
Alliance Healthcare. 

Prescribing Information 

(Please refer lo the full Summary of Product Characteristics before 

Avamys' T Nasal Spray Suspension 
(fluticasone furoate 27.5 micrograms/metered spray) 
Uses: Treatment of symptoms of allergic rhinitis in adults and 
children aged 6 years and over. Dosage and Administration: 

For intranasal use only. Adulls: Two sprays per nostril once daily 
(total daily dose, 110 micrograms). Once symptoms controlled, use 
maintenance dose of one spray per nostnl once daily (total daily 
dose, 55 micrograms). Reduce to lowest dose at which effective 
control of symptoms is maintained. Children aged 6 to 11 years 
One spray per nostnl once daily (total daily dose, 55 micrograms) 
If patient is not adequately responding, increase daily dose to 
1 10 micrograms (two sprays per nostril, once daily) and reduce 
back down to 55 microgram daily dose once control is achieved. 
Contraindication: Hypersensitivity to active substance or 
excipients. Side Effects: Systemic effects of nasal corticosteroids 
may occur, particularly when prescribed at high doses for prolonged 
periods Very common epistaxis. Epistaxis was generally mild lo 
moderate, with incidences in adulls and adolescents higher in 
longer-term use (more than 6 weeks). Common: nasal ulceration. 
Rare hypersensitivity reactions including anaphylaxis, angioedema, 
rash, and urticaria. Precautions: Treatment with higher than 
recommended doses of nasal corticosteroids may result in clinically 
significant adrenal suppression. Consider additional systemic 
corticosteroid cover during periods of stress or elective surgery. 
Caution when prescribing concurrently with other corticosteroids 


1 . Avamys Summary of Product Characteristics 2009. 

2 Salter M, Biggadike K, Matthews JL et al. Am J Physiol Lung Cell Mol Physiol 2007; 293: 660-667 

3 GlaxoSmithKline Data on File AVS/DOF/09/42575/1 . 

4. MIMS (Monthly Index of Medical Specialities). Online, last accessed date April 2010. 
5 Flixonase Summary of Product Characteristics 2010. 

Growth retardation has been reported in children receiving some 
nasal corticosteroids at licensed doses. Monitor height of children. 
Consider referring to a paedialric specialist. May cause irritation of 
the nasal mucosa Caution when treating patients with severe liver 
disease, systemic exposure likely to be increased. Nasal and 
inhaled corticosteroids may result in the development of glaucoma 
and/or cataracts Close monitoring is warranted in patients with a 
change in vision or with a history of increased intraocular pressure, 
glaucoma and/or cataracts. Pregnancy and Lactation: 
No adequate data available Recommended nasal doses result in 
minimal systemic exposure. It is unknown if fluticasone furoate 
nasal spray is excreted in breast milk. Only use if the expected 
benefits to the mother outweigh the possible risks to the foetus or 
child. Drug interactions: Caution is recommended when co- 
administering with inhibitors of the cytochrome P450 3A4 system, 
e.g. ketoconazole and ritonavir Presentation and Basic NHS 
cost: Avamys Nasal Spray Suspension. 120 sprays: £6.44 
Marketing Authorisation Number: EU/1/07/434/003. Legal 
category: POM PL holder: Glaxo Group Ltd, Greentord, 
Middlesex, UB6 ONN, United Kingdom Last date of revision: 
January 2010. 

Adverse events should be reported. Reporting forms and 
information can be found at Adverse 
events should also be reported to GlaxoSmithKline on 
0800 221 441. 

Avamys is a n 

trademark of the GlaxoSmithKline group of 

Avoid concomitant administration of inhibitors of the 
cytochrome P450 3A4 system, e.g ketoconazole, and ritonavir. 
Pregnancy and lactation: Clinical data is not available. Balance 
risks against benefits. Side effects: Very common: Epistaxis. 
Common: Headache, unpleasant taste, unpleasant smell, nasal 
dryness, nasal irritation, throat dryness, throat irritation. Very 
rare: Cutaneous hypersensitivity reactions, angioedema, 
bronchospasm, anaphylactic reactions, glaucoma, raised 
intraocular pressure, cataract, nasal septal perforation. 
Presentation and Basic NHS cost: Flixonase Aqueous Nasal 
Spray: 150 metered sprays - £11.01 Market Authorisation 
Number: PL 10949/0036. Market Authorisation Holder: Glaxo 
Wellcome UK Limited trading as Allen & Hanburys, Stockley Park 
West, Middlesex, UB11 1BT. Legal category: POM. Date of 
preparation: January 2010. 

Prescribing Information 

(Please refer to the full Summary of Producl Characteristics 
before prescribing.) 

Flixonase 8 ' Aqueous Nasal Spray 
(fluticasone propionate 50 micrograms/metered spray) 
Uses: Prophylaxis and treatment of seasonal allergic and 
perennial rhinitis in adults and children aged 4 years and over 
Dosage and administration: For intranasal use only. Adulls: Two 
sprays per nostril once daily in the morning. Once symptoms 
controlled, use maintenance dose of one spray per nostril once 
daily. Two sprays per nostril twice daily may be required 
Maximum daily dose four sprays per nostril. Children aged 4 to 11 
years: One spray per nostril once daily in the morning. One spray 
per nostril twice daily may be required. Maximum daily dose two 
sprays per nostril For full therapeutic benefit regular usage is 
essential. The minimum dose should be used at which effective 
control of symptoms is maintained. Contra-indication: 
Hypersensitivity to any of its ingredients Precautions: Local 
infections should be appropriately treated. Caution when 
transferring patients from systemic steroids. Systemic effects of 
nasal corticosteroids may occur at high doses for prolonged 
periods. Growth retardation has been reported in children 
receiving some nasal corticosteroids at licensed doses. Monitor 
height of children. In addition, consider referring patients to a 
paediatric specialist Treatment with higher than recommended 
doses of nasal corticosteroids may result in clinically significant 
adrenal suppression. Consider additional systemic corticosteroid 
cover during periods of stress or elective surgery. 

6 Meltzer E, Stahlman J ef al. Clin Ther 2008; 30: 271-9. 

7 Fokkens WJ, Jogi R, Relnartz S el al. Allergy 2007; 62: 1078-1084. 

8. Kaiser HB, Nacleno RM, Given J et al. J Allergy Clin Immunol 2007; 119(6): 1430-1437. 

9. Jacobs R, Martin B, Hampel F et al. Curr Med Res Opin 2009; 25: 1393-1401. 

10. Berger WE, Godfrey JW, Slater AL. ExperOpin Drug Deliv. 2007; 4(6): 689-701. 

Adverse events should be reported. Reporting forms and 
information can be found at Adverse 
events should also be reported to GlaxoSmithKline on 
0800 221 441. 

Flixonase is a registered trademark of the GlaxoSmithKline group 
of companies. 


For more information on Avamys visit 

Date of Preparation: May 2010 UK/FF/0070/10 

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The first tears came as the Court of 
Appeal heard how Carmel Shelter 
had collapsed after taking 
propranolol instead of the 
prednisolone prescribed. Elizabeth 
Lee dabbed her eyes, lent into her 
father for comfort, and probably 
wished for the billionth time that she 
could have put the clock back to 
August 2007 

It was then that a diligent, 
20-something pharmacist handed 
out a prescription for beta blockers 
instead of steroids. It had been a 
long shift, she momentarily slipped 
beneath her own high standards, and 
she made a mistake 

Of course you feel for Ms Shelter's 
family. Ms Lee's mistake can't be 
brushed aside and forgotten about. 
A grandmother's health suffered 
as a result and she later died - of 
an underlying condition and not 
the error. 

If that was my grandmother or 
yours we would feel angry and want 
Justice. But my overriding sentiment 
after attending Ms Lee's Court of 
Appeal hearing last week is that 
justice hasn't really been served. 

Everything indicates Ms Lee is an 
exceptionally honest and dignified 
person. She quit as a pharmacist as 
soon as her error came to light. She 
has shunned the limelight - 
repeatedly stressing her desire to 
pursue a quiet life. In the limited 
conversations she has had with C+D 
she has always spoken of her sorrow 
for what she did, extended her 

condolences to Ms Sheller's family 
and never tried to make excuses. 

One of the appeal court judges 
made a telling counter attack to this 
argument. He drew a parallel to 
careless driving. You can be an 
upstanding citizen, but if you 
momentarily take your eyes off the 
road and cause an accident then 
you have to face the consequences. 

That might be true, but what if 
the accident took place on a 
particularly hazardous piece of 
road? Would it not be better to 
tackle road safety instead of making 
the driver a scapegoat? 

For Ms Lee the personal cost of 
this case has been vast. It was 
impossible to reconcile the wan 
individual who sat before the court 
last week with the vibrant woman of 
three years ago. In the quest to 
avenge one life, another has been 
destroyed. A one-time talented 
pharmacist now works as a cleaner 
for a local church, the court heard. 
That seems a tragic loss for both 
pharmacy and society as a whole 

Thankfully, the Court of Appeal 
offered some redemption: it quashed 
Ms Lee's custodial sentence. One 
avenue for prosecuting errors has 
been partially plugged thanks to Ms 
Lee's appeal. It's up to us to 
complete the job and ensure her 
legacy (p10) is as the pharmacist 
who brought an end to criminal 
prosecutions for dispensing errors. 

Max Cosney, News Editor 

6 Dispensing error talks hit "difficulties" 

7 Guernsey threatens break from RPSGB 

8 Script charge shake-up proposed 
10 The legacy of Elizabeth Lee 

13 Product and market news 

14 Time for sector to make a stand 

15 The Finance Zone 

16 Xrayser and Terry Maguire 
25 Classified 

30 Postscript 

17 Update: Interpreting blood test results 

Part 1 looks at disease management 

19 Practical Approach 

Complementary medicines for arthritis 

20 Eye and earcare 

Making the most of this £64 million market 

24 Childhood constipation 

What you need to know about new Nice guidelines 

26 Careers 

Improve your time management skills 

© UBM Medica, Chemist + Druggist incorporating Retail Chemist, Pharmacy Update and Beauty Counter. Published Saturdays by UBM Medica, Ludgate House, 245 Blackfriars Road, London SE1 9UY C + D online at 
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05.06.10 5 


Dispensing error protection 
negotiations 'in difficulty' 

EXCLUSIVE Prosecution threat remains after talks stall, Elizabeth Lee appeal court hears 

Max Gosney 

Negotiations have stalled on a deal 
to protect pharmacists from criminal 
prosecution for one-off dispensing 
errors, C+D can reveal. 

Industry officials have clashed 
with the Crown Prosecution Service 
(CPS) over establishing the public 
interest in error cases, London's 
Court of Appeal heard last week. 

"Difficulties have arisen in 
negotiations," CPS informed the 
court, when asked for an update on 
the guidance during former locum 
Elizabeth Lee's appeal against a 
custodial sentence for a dispensing 

When pushed by judges for a 
revised publication date, prosecutor 
John Price said: "Nothing is 
imminent ... I am unable to give the 
court a date. I'm instructed [by the 
CPS] the parties have encountered 

The setback comes despite 
repeated pledges from the CPS that 
the guidance was in the final stages. 
Talks have taken place between 
prosecutors, the MHRA and the DH. 
The protection deal was first pledged 
almost a year ago. 

Lord Justice Aitkens, one of the 
three appeal court judges in the 
Elizabeth Lee case, said: "With 
three parties you can imagine 

Prosecutors, the MHRA and the DH have clashed over public interest in error cases 

papers swirling around for months 
or even years." 

The CPS statement on guidance 
dealt a blow to Ms Lee's defence, 
according to a member of her 
legal team. 

PDA chairman Mark Koziol said 
they had hoped to nullify both 
parts of the Medicines Act that 
provide the platform for criminal 
prosecution of pharmacists. 

But because of the guidance delay, 
section 64.1, which governs wrong 
product supply, had to be left "to lie 
on the table". 

Ms Lee successfully overturned 
her conviction, made under a section 
85.5 labelling offence, at the 

hearing. Her conviction was then 
substituted for the 64.1 offence 
at the prosecution's request 
and resulted in a £300 fine for 
Ms Lee. 

The CPS was not available for 
comment as C+D went to press. 

The DH said interim guidance for 
prosecutors had been drafted. A 
spokesperson added: "The guidance 
is still under discussion and will be 
published once agreed." 

The RPSCB urged all sides to 
urgently agree a deal. Chief 
executive Jeremy Holmes said: 
"We really need action on this issue 
to provide clarity. . . We urge the 
parties to redouble their efforts." 

What is the legacy of 
Elizabeth Lee? 

See analysis, p10 

Elizabeth Lee: 
Thanks for your 
kind words' 

Elizabeth Lee has thanked C+D 
readers for their support during 
her trial and expressed her 
desire to return to a "quiet and 
normal life". 

Speaking outside the Court of 
Appeal last week, the former 
locum told C+D: "Bless you and 
your kind words." 

C+D passed on messages of 
support to Ms Lee following her 
conviction for a single 
dispensing error last April. 

Ms Lee left the Court of 
Appeal in tears after judges 
substituted her custodial 
sentence for a £300 fine. 

In a written statement she 
said she was relieved at the 
court's decision. A custodial 
sentence had been a "difficult 
burden to bear", she said. 

The written statement from 
Ms Lee added: "I now wish to 
finally put this tragic episode 
behind me and hope that I will 
be allowed to return to a quiet 
and normal life." 

The court heard how Ms Lee 
had been working as a part-time 
cleaner for a local church after 
choosing not to work as a 
pharmacist following her error. 

Read Elizabeth Lee's 
statement in full at: 

PSNI Statutory Committee upholds removal from register 

A County Down pharmacist has had 
his bid to be restored to the 
pharmaceutical register refused by 
the PSNI Statutory Committee. 

Derek Webb of Groomsport, who 
was superintendent pharmacist of 
Webb's Pharmacies, had his name 
removed from the register for non- 
payment of fees in October 2006. 

Mr Webb had applied to have his 
name restored to the register in 
2010. However, since he had two 
convictions dating from September 

2006 his application had to be 
considered by the Statutory 

The previous convictions related 
to advertising a POM medicine and 
placing on the market for sale a 
relevant medicinal product that 
did not have a Marketing 
Authorisation (MA). 

The inquiry was told that on 
purchasing his fifth pharmacy in 
December 2004, Mr Webb obtained 
the rights to "The Portavogie 

Teething Mixture" and he supplied 
this medicine from all his 
pharmacies as well as by mail order. 

The teething mixture did not have 
a MA and contained Trimeprazine, 
a POM. Following a complaint 
from the public an extensive recall 
of the medicine was undertaken in 
early 2005. 

At the hearing Mr Webb accepted 
that his actions had brought into 
question his fitness to practise. 

He argued that his absence from 

the register had coincided with 
a period similar to one that might 
be imposed had the matter been 
dealt with by the Statutory 

Tim Ferris, chairman of the 
Statutory Committee, told Mr Webb 
that he had failed to convince the 
committee that he had sufficient 
insight into the seriousness of what 
he had done and had not take 
sufficient steps to prepare himself 
for practice. Contributed 

6 Chemist Druggist 05.06.10 

Get news straight to your inbox 


Guernsey threatens 
to break from RPSGB 

EXCLUSIVE Island pharmacists set to form own professional body 

Chris Chapman 

Pharmacists on Guernsey are poised 
to form their own professional body 
after regulatory powers are passed 
to the General Pharmaceutical 
Council (GPhC), C+D can reveal. 

In a letter sent to all pharmacists 
in the Channel Island's bailiwick, 
which also includes Alderney and 
Sark, the Guernsey branch 
committee has proposed to "totally 
devolve [from the RPSGB] and form 
a new independent group" 

The move comes after growing 
dissatisfaction with professional 
leadership from the Society among 

One Guernsey pharmacist, 
who asked to remain anonymous, 
said crown dependencies, which 
also include Jersey and the Isle of 
Man, felt "left out" of the Society's 
future plans. 

Society director for England 
Howard Duff said the Society was 
"making every effort" to meet the 
needs of all pharmacists in the UK. 
"We value and need the contribution 
of all members to build a strong 
leadership body and very much hope 
members in Guernsey decide to 
remain with the Society," he said. 

However, it would be cheaper for 
pharmacists practising in the 
bailiwick to band together and fly in 
an expert each month to deliver a 
CPD session than for them each to 

pay the Society's proposed £192 
membership fee, the Guernsey 
pharmacist countered. 

A Jersey pharmacist confirmed 
resentment toward the Society in 
the dependencies, describing the 
new body as "just trying to usurp 
what the NPA is offering". However, 
there were no plans for Jersey to 
form its own breakaway group, the 
pharmacist stressed. 

The Society's Isle of Man branch 
also confirmed its intent to remain 

with the future professional 
leadership body 

Membership of the Guernsey 
breakaway body would be obligatory 
for pharmacists on the islands, 
numbering around 40. A fee of £10, 
and £5 for retired pharmacists and 
technicians, has been proposed. 

A vote whether to go ahead and 
form the splinter faction, 
prospectively called the Guernsey 
Pharmacist Group, was due to be 
held on Thursday. 

PNA questionnaires hit pharmacies 

Some PCTs are quizzing contractors 
on unnecessary commercial details 
as they work to complete their 
pharmaceutical needs assessments 
(PNAs), PSNC has warned. 

But the committee stressed 
contractors should complete the 
questions where they were 
appropriate to the task. 

PSNC said trusts were now 
working "full steam ahead" to 
complete their PNAs after 
regulations concerning them came 
into force in May. Many are sending 
contractors questionnaires to help 
determine current service provision 
and willingness to provide services. 

There have previously been 
concerns that PCTs would not 
have the capability to produce 
effective PNAs, which will 
eventually be used as the basis of 
commissioning and new contract 
application decisions. 

But Steve Lutener, head of 
regulation at PSNC, said much of 
the feedback from LPCs so far on 
PNAs had been positive 

However, he warned that in some 
cases the trusts had not held 
detailed discussions with the 

And he further cautioned that 
some trusts had been asking 

questions that were irrelevant, 
such as the number of printers in a 
pharmacy, or commercially 
sensitive, such as details on staff 
and their qualifications. 

Mr Lutener said: "We are 
encouraging completion of the 
questionnaires so long as the 
questions asked are appropriate and 
proportionate." ZS 

What has your PCT 
asked you about PNAs? 

Dispensing danger 

More than 6.3 million Britons 
have given medicines to family 
and friends for whom they 
were not prescribed, research 
by Lloydspharmacy has revealed. 
The multiple has raised the 
danger of passing on prescription 
drugs and urged patients to 
return unused medicines to their 
local pharmacies to be disposed 
of safely. 

Qp'lhC coBiisyltatBon 

Results of the consultation on the 
GPhC's draft rules were set to be 
the focus of proceedings at this 
week's council meeting. Papers 
from the meeting will be made 
available on the Council's website: The 
GPhC was unable to comment on 
the results of the consultation as 
C+D went to press. 

Alcohol advice 

Pharmacies should take action to 
support patients who misuse 
alcohol, Nice has said. Under 
new public health guidance, 
pharmacists are urged to offer 
structured advice on alcohol, 
including highlighting potential 
harms, barriers to change, and 
strategies to reduce alcohol 

NPSA targets 

The National Patient Safety 
Agency has unveiled the 10 key 
areas it aims to tackle to reduce 
patient harm across the NHS. 
The list includes focus on unsafe 
use of insulin, anticoagulation 
therapy, falls prevention and 
treatment of patients with 
learning disabilities. 

Illegal slimming pills 

A 44-year-old man has received a 
six month prison sentence for 
illegally selling and supplying 
unlicensed slimming pills 
containing ephedrine. The MHRA 
said the pills had been sold online 
at as 
well as via online auction sites, 
and called the case "another 
example of the danger of buying 
any type of drug from an 
unregulated source". 

05.06.10 hei 



Get your digest of all the day's big health news 

Key role for pharmacy in 
script charge shakeup 

Report recommends all long-term conditions exempted from charges 

Will the coalition 
government be good 
for pharmacy? 

"I wait with baited breath and 
believe the proof of the pudding is 
in the eating. We have got to wait 
and see." 

JonThroup, Burrows & Close 
Pharmacy, Calverton, 

"I would say yes because I think that 
they will offer a new kind of politics, 
and we need to give them a chance 
to deliver it." 

Jayne Welsh, Tesco Pharmacy, 

Web verdict 



pharmacists have little faith in the 
Conservative-Liberal Democrat 
partnership, it seems, with over 
three quarters of our poll 
respondents believing they have 
little to offer the sector. 
Next week's question: 
How much longer will pharmacy be 
kept waiting for CPS guidance on 
dispensing errors? Vote at 

Chris Chapman 

A £430 million overhaul of 
prescription charges in England to 
make all patients with long-term 
conditions exempt could see 
patients registered with pharmacists. 

In a review of prescription charges 
for the Department of Health (DH) 
published this week, Royal College of 
Physicians president Ian Cilmore said 
patients with conditions lasting at 
least six months, including 
conditions such as hypertension, 
should be made exempt from 
charges "as soon as possible". 

The report, which DH officials saw 
in November, estimates the total 
cost of extending the exemption as 

£430m. However, the burden could 
be eased by a phased reduction in 
prescription pre-payment certificates 
(PPC) prices, cutting the annual cost 
to just £60 by 2012-13. 

To achieve this, pharmacies would 
have to take the lead in helping 
patients buy pre-payment 
certificates, professor Cilmore said. 

"This might include wider 
availability of PPCs at pharmacies 
and the ability to automatically 
qualify for a PPC after paying the 
equivalent cost through 
accumulated individual prescription 
charges, for example through a 
loyalty mechanism (possibly using 
smartcard technology) or 
registration with a pharmacist." 

Currently, only 1,600 pharmacies 
in England are estimated to offer the 

PSNC head of NHS services 
Alastair Buxton was broadly 
supportive of the proposed move, 
but warned that it could lead to 
added bureaucracy for pharmacists. 
PSNC backed the abolition of all 
prescription charges in England, but 
understood the government's 
hesitance to implement the change 
due to the economic climate, Mr 
Buxton added. 

DH minister Earl Howe welcomed 
the report, but warned that any 
decision would be taken in context 
of the next NHS spending review, 
which is due to report in the autumn. 

Clinical debate C+D's Chris Chapman looks at the evidence behind the headlines 

Statins: why familiarity must 
not breed complacency 

Ask any pharmacist to name the 
five drugs they most commonly 
dispense and you'll no doubt find a 
statin on the list. But are we giving 
them enough attention? 

A new paper in the BMJ suggests 
we aren't. The team used UK 
general practice database 
QResearch to gather data from 
368 CP surgeries on some two 
million patients. Of these, around 
226,000 patients were started on 
statins, most commonly 
simvastatin or atorvastatin. The 
team then studied a range of 
adverse outcomes over six years. 

They found that for every 
10,000 women at high risk of CVD 

treated with a statin, they would 
prevent 271 cases of CVD and eight 
cases of oesophageal cancer. So far, 
so good. However, the data suggests 
there would also be 74 extra 
patients with liver dysfunction, 23 
with acute renal failure, 307 with 
cataracts, and 39 with myopathy. 

The figures were similar in men, 
who were at an even greater risk of 
myopathy (110 cases) but lower risk 
of cataracts (191 cases). It didn't 
make much difference which statin 
was prescribed in terms of adverse 
reactions, although patients on 
fluvastatin were at a higher risk of 
liver dysfunction. These risks 
persisted during treatment, but were 
highest in the first year. 

And this paper comes hot on the 
heels of an MHRA warning of an 
increased risk of myopathy at high- 
dose simvastatin (80mg), based on 
data from the 12,064-patient 
SEARCH study. 

So will there be a shift in statin 
prescribing? I'm not so sure. The 
risks associated with statin therapy 
are well known. And, as a BMJ 

editorial argues, the benefits 
of therapy probably outweigh 

The message for pharmacists is 
simply to be watchful. No other 
healthcare professional is in such 
an ideal position to intervene 
when it comes to adverse 
reactions - particularly when it 
comes to OTC simvastatin. An 
MUR, or simply asking a patient 
about their health, could nip any 
problems in the bud. 

Statins are of proven benefit 
when used within guidelines. That 
said, the risks of statin therapy, 
like any other medicine, shouldn't 
be forgotten just because the 
drugs are dispensed every day. 

To discuss this subject in 
private with your pharmacy 
colleagues, join the debate in 
C+D's Linkedln group at - search for 
Chemist and Druggist. 

Chat with Chris on Twitter: 

8 05.06.10 

of fee h?vfwsr s«»d? 

/ 120mg 

Fexofenadine Hydrochloride 

30 Tablets 



Fexofenadine Hydrochloride 
Telfasl 1 20 mq film-coaled tablets 

The lablets are film-coated peach coloured tablets containing 120 mg 
lexolenadine hydrochloride, equivalent to 1 1 2 tog ol fexofenadine. 

For relief ol symptoms associated with seasonal allergic rhinitis. 
Dosage & Administration: 

For the treatment ol seasonal allergic rhinitis in adults and children aged 
12 years and over, the recommended dose ol lexolenadine hydrochloride 
is 120 mg once daily belore a meal The etticacy and salely ol lexolenadine 
hydrochloride has not been established in children under 6 years ol age. 


Known hypeisensitivily lo any ol the product's ingredients 

Studies in adults have shown thai il is not necessary lo adjust the dose ol 
lexolenadine hydrochloride in the elderly or in renally or hepalically 
impaired patients However, lexolenadine should be administered with 
care in these special groups 

Side effects (Please refer to the Summary ot Product 
Characteristics for full side-effect details): 

In controlled clinical trials the incidence ol commonly reported adverse 
events observed with lexolenadine was similar lo thai observed with 
placebo. These adverse events were headache, drowsiness, nausea, 
dizziness, and sleep disorders or paronina. such as nightmares. In rare 

cases rash, hypersensitivity reaclions with manifestations such as 
angioedema. chest lightness, dyspnoea, and systemic anaphylaxis have 
also been reported. 
Pregnancy & Lactation: 

Fexofenadine is not recommended in pregnancy or tor mothers breast- 
feeding their babies, due lo absence ol experience in this group ol patients 
Legal Category: POM 

Marketing Authorisation Number: PL 04425/0157 
NHS Price: Pack of 30 Tablets: £ 6.23 
Further information is available liom Winthrop Pharmaceuticals, 
One Onslow Sheet, Guildford, Surrey. GU1 4YS. 

Date ot Revision of Prescribing Information: April 2009 


Economise without compromise 

Adverse events should be reported and information about adverse event reporting can be found on 
Adverse events should also be reported to Winthrop Pharmaceutical UK Ltd as follows:- Email: Tel. 01483 554242 Fax.:01483 554806 

For lurlher inlormalion please visit our websile uk. freephone 0800 854431 or contact Winthrop Pharmaceuticals. 1 Onslow Street. Guildlord, Surrey. GU1 4YS Fax number 01483 554831 Date ol Preparation April 2009 STW374 


C+D breaking news: get it first 

The legacy of Elizabeth Lee 

The former locum had the jail term she received for a dispensing error quashed last week. But 
will her appeal victory keep similar cases out of the criminal courts? Max Gosney reports 

For one pharmacist at least the 
threat of criminal punishment for a 
single dispensing error has been 
lifted. Elizabeth Lee left the Court of 
Appeal on May 26 with her 
suspended jail sentence quashed. 
The reversal will bring heady cheers 
in dispensaries across the land, but 
this remains a victory tinged with 

But first let's take the positives. 
The highest court in the land has 
overturned a custodial sentence for 
a dispensing error. Ms Lee was a 
promising young pharmacist when 
she arrived for a locum shift at a 
Tesco store in Windsor in August 
2007. Later that day she supplied 
propanolol instead of the prescribed 
prednisolone to cancer patient 
Carmel Shelter, who later died. 

The mistake saw Ms Lee punished 
with a three-month suspended jail 
term by the Old Bailey last March. 
The presiding judge stressed Ms Lee 
bore no factual or legal responsibility 
for Mrs Shelter's death, but she was 
convicted under section 85.5 of the 
Medicines Act nevertheless. 

Just over one year on and the 
Court of Appeal nullified the terms 
of that conviction. The court ruled 
that section 85.5, which makes it an 
offence to attach the wrong label 
to a medicine, should not be applied 
to employed or self-employed 

The judgement is a clear boost for 
employees and locums who will now 
avoid the threat of criminal charges 
under labelling offences. The risk for 
contractors though remains as the 
Court of Appeal ruled pharmacy 
owners are still accountable for 
breaches of section 85.5. 

But even though the ruling lifts 
the threat of prosecution for 
employees and locums under one 

Judgement day: Mark Koziol and the PDA battled to overturn Ms Lee's conviction 

part of the Medicines Act, it leaves a 
second area untouched. Despite Ms 
Lee's successful appeal, pharmacists 
could face criminal prosecution for 
wrong product supply under section 
64.1 of the act. Ms Lee was originally 
charged under both wrong product 

supply (64.1) and attaching the wrong 
label (85.5) offences. However, as 
she pleaded guilty to the 85.5 
breach, the judge chose not to 
proceed with the charge under 64.1. 

But once Ms Lee's conviction 
under 85.5 was quashed at last 
week's appeal, the prosecution 
requested judges substitute for the 
64.1 offence instead. The Court of 
Appeal judges called for the matter 
to be considered at a retrial. But, Ms 
Lee has been explicit in her desire 
not to return to the court again. "It 
would be like returning to the scene 
of a road traffic accident," one 
member of her legal team told C+D. 

The prosecution advised the Court 
of Appeal that they would push 
ahead for retrial unless it dealt with 

the 64.1 offence immediately. Ms 
Lee's legal team had no choice but to 
concede. The judges switched the 
85.5 conviction for a 64.1 offence 
and issued Ms Lee a £300 fine. 

This substitution deal means 
dispensing errors remain open to 
criminal prosecution and it has left a 
sense of unfinished business around 
those closest to the case. Mark 
Koziol, PDA chairman and member 
of Ms Lee's legal team, says: "As a 
consequence of events we did not 
get an opportunity to put our legal 
arguments about the appropriateness 
of the section 64.1 offence as we feel 
that had we done so, then more 
progress could have been made." 

Pre-hearing, Ms Lee's legal team 
had been confident of successfully 
tackling the 64.1 offence. Their 
chances hinged on the prompt 
publication of dispensing error 
guidance from the Crown 
Prosecution Service (CPS) promising 
pharmacists greater protection 
against prosecution for errors. 

Ms Lee's legal team aimed to 
convince judges a retrial under 64.1 
could not take place with rules over 
dispensing errors about to change. 
But the bid was to be scuppered 
almost immediately. Within minutes 
of the Court of Appeal hearing, the 
CPS said it could not guarantee 
guidance arriving anytime soon. In 
fact discussions between the CPS, 
the Department and the RPSCB had 
hit "difficulties" over defining the 
public interest in dispensing error 
cases, judges were told. 

"We were dealt a curve ball by 
CPS saying this was in the long 
grass," Mr Koziol told C+D outside 
the court room. "That wasn't our 
understanding and it meant we had 
to focus on the 85.5 offence. We 
could have overturned both." 

Ultimately the appeal fell short 
of total victory. But it would be a 
harsh critic who considered it a 
disappointment. Ms Lee can get on 
with her life free from the burden of 
a custodial sentence and 
pharmacists are better protected 
against prosecution for errors. The 
sector must now make sure this 
protection becomes full rather than 
partial without losing another 
aspiring pharmacist like Ms Lee 
along the way. 

The Elizabeth Lee Court of Appeal case 


• Custodial sentence quashed and switched to a £300 fine 

• Employees and locums shielded from labelling offences 

■ • Fine, not jail term is now the precedent for Medicines Act breach 
v« Wrong product supply offence remains 

• Ms Lee unlikely to practise again 

• Nq sign of dispensing error protection guidelines in near future 

10 Chemist+Druggist 05.06.10 

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be in the know. 

Make sure your voice is heard. With your involvement, your national pharmacy boards and your 
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16 <J& 





Reward locums with fair pay for their expertise 

I write with concern about the 
recent development in provision of 
MUR services in some company/ 
multiple-owned pharmacies. 

I think the issue regarding provision 
of essential, advanced and enhanced 
services needs further clarification, 
as some companies expect locums 
to do two MURs per day on top of 
providing an essential service. 

It can also be a prerequisite that 
locums be MUR-accredited to get 
the placement. And he/she is forced 
to do MURs as if they are an 
essential service, and do not get any 
extra remuneration for doing MURs. 

It is important this unfairness is 
addressed, because locums have 
invested time and money to attain 
MUR accreditation, primarily for 
their own professional and financial 
betterment and not for companies 
to exploit this. This applies particularly 

Talk to C+D on Twitter. Sign 
up at and follow 
CandDZoe, CandDChris, 
CandDMax, CandDJennifer, 
GaryParagpuri, CandDHannah 
and ChemistDruggist. 

Contact us 

^ Email us your letters, 
/^p including your name, 
address and contact 
number, to: 



to MURs but is equally relevant to 
other enhanced services that locums 
have invested in getting accreditation. 

The provision of advanced and 
enhanced services by a locum 
should be treated as a separate 
agreement from essential services in 
much the same way the contractor is 
paid extra for such services. 

Additionally, it is difficult and 
more stressful to provide a safe and 
efficient pharmaceutical service 
when the only 'responsible' 
pharmacist is struggling between 
providing an essential service and 
being in consultation with a patient 
on advanced or enhanced services. 

A mutually beneficial option has to 
be developed with a patient focus. 

Alternatively, companies could 
use an MUR-accredited employee or 
locum to meet targets for maximum 
financial reward without subjecting 
locums or employees to rather 
unsafe juggling of responsibilities. 

Perhaps pharmacist area 
managers or other desk-based 
company pharmacists could make a 
more constructive contribution by 
going into branches to conduct 
MURs rather than frontline 
pharmacists being asked to do more 
with/for less. 

Name and address supplied 





Highlights from C+D on Twitter 


From nights out to the Time Warp, join the debate at • 1 1 ^ j 

J S 


@CaryParagpuri: Just spoken to our compere for the C+D Awards - you re in <J5l 
for a fantastic evening is all I can say. » 

@CandDHannah: Looking forward to staying in the place where The Rocky \, r ;< 

Horror Show was filmed [for the CAMRx convention]. In fact, weren't they < Os_. 
supposed to be at a convention?! 

@CandDChris: @CandDHannah yeah, an annual Transylvanian convention. If 
you don't get a Time Warp in, I shall be disappointed. 

@CandDHannah: Nice has claimed minimum pricing on alcohol will reduce 
excessive drinking by 10%. Based on what? Irish law in 1987 didn't work. 

12 Chemist+Druggisl 05.06.10 

Check out what's on TV this week 


Anti-mosquito spray Incognito in 
new formula relaunch 

Anti-mosquito range Incognito will 
relaunch its spray in a new formula 
from this month. 

The new formulation has been 
tested by the London School of 
Hygiene & Tropical Medicine 
(LSHTM) as giving 100 per cent 
protection against Anopheles 
gambiae (African) mosquitoes, and 
has been approved by the Trading 
Standards Institute as "clinically 
proven to protect against malaria", 
according to the company. 

Incognito spray will continue to 

contain Javanese citronella, but in a 
lower concentration than the 
previous formulation. 

It will now also contain 
Eucalyptus maculata citriodora, 
which has also been tested by the 

The research was reported in the 
British Medical Journal. 

Price: £7.99 

Tel: 0207 221 0667 

Market focus 

• The insect repellent market 
is worth £6.9 million. 

• Pharmacy accounted for 28 
per cent of the market sales. 

• The top selling insect 
repellent brands are Jungle 
Formula, own brand and Autan. 

Source: 1RI value sales, 52 weeks to 
February 20, 2010 

Price drop for Omnitrope 

Slimshot price cut 

DTP has announced a summer 
price reduction for Slimshot from 
£16.99 to £9.99. Slimshot is a 
weight loss drink made up from 
effervescent tablets. The product 
is available in Tesco, Superdrug 
and some independent 
pharmacies, according to DTP. 

Tel: 0115 924 8160 

Sandoz has announced a price drop 
for Omnitrope (liquid somatropin for 
injection) from June 1. 

The recombinant growth 
hormone is now the cheapest in the 
NHS price list, Sandoz says. 

Nice published guidelines last 
month on the relative cost and 
effectiveness of somatropin 
products to treat child growth 
deficiences. The guidance now 
includes Omnitrope as one of seven 
recommended somatropin products 
- the first time that Nice has 

recommended the use of a 
biosimilar product, says Sandoz. 

The price for Omnitrope 5mg will 
reduce from £91.33 to £86.74; for 
5mg/1.5ml the price will drop from 
£456.65 to £433.82 and for 10mg/ 
1.5ml from £913.20 to £867.64. 

Price: £433.82 (5mg/1.5ml); 

£913.30 (10mg/1.5ml) 

Pip codes: 325-7722; 335-3067 


Tel: 01420 478301 

Simple has relaunched its Simple 
Baby range, which is available in 
Boots, Sainsbury's, Morrisons and 
Superdrug. The range comprises 
moisturising wipes, all-in-one 
wash, moisturising bath wash, 
moisturising shampoo and talc. 

Tel: 0121 712 6523 

Oxford Nutrascience is set to launch 
two supplement products using its 
confectionery system that it says 
uses soluble fibres to allow functional 
ingredients such as vitamins to be 
added without compromising taste, 
texture and stability. 

One chew is a cranberry 
supplement and the other is a 
children's chew that contains pre- 

simple Baby relaunch New supplements to chew over 

biotic fibre, omega-3 and vitamins A, 
C, D and E. They are set to launch in 
the second half of the year. 

The launch announcement follows 
an "exclusive" agreement last 
month with European confectionery 
manufacturer Lamy Lutti. 

Oxford Nutrascience 

Retail talk 

Do national awareness 
campaigns boost 
associated retail sales? 

"I have to say 
they don't really 
affect sales, but 
they do help with 
local health 
campaigns. We 
have had a lot of 
uptake onto those schemes and this 
improves our professional image as a 
good source of help and advice." 
Linda Bracewell, Baxenden 
Pharmacy, Lancashire 

"Some of them 
are quite good - 
in particular No 
Smoking Day and 
Know Your 
Numbers, which 
is about blood 
pressure. However, National Obesity 
Day didn't have much of an effect." 
David Badham, Stewart 
Pharmacy, Evesham, Worcs 

Web verdict 



Off the shelf view: Three quarters 
believe awareness campaigns boost 
pharmacy sales, but the remainder 
have doubts about their impact 
Some suggest campaigns have a 
bigger effect on uptake of services. 
Next week's question: 
Did a mostly unseasonably warm 
May boost your sales? Vote at 

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are connected to a better future. So, with the demands being made on you by the current National Programmes, get better 
connected today. Call your ProScript LINK Account Manager, email or visit 

C °WWECTING YOU 10 ft^TER Furu ftf p ro 



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Test yourself with the C+D news quiz. Go to 

Time for sector to make a stand 

With the NHS financial landscape looking decidedly bleak, Alliance Healthcare chairman 
i in b m ii i ves only u united pharmacy front will see the sector survive 

At last the protracted general 
election activity is at an end and we 
have a coalition government. Its task 
will not be an easy one as recession 
will lead to spending cuts, high 
unemployment and increasing 
pressures on the NHS. I wish David 
Cameron and Nick Clegg well, but 
the more I think about this, the more 
I see parallels with community 

Our profession will not be 
immune from these changes and I 
fear that the removal of £20 billion 
from the NHS budget between 2011 
and 2014 will change the face of 
community pharmacy as we know it. 

The profession needs to face up 
to the fact that in these times of 
austerity we're not going to be 
immune from it. 

The days of making relatively easy 
money are disappearing and if we're 
going to survive, as I believe we will, 
we're going to need strong and 
dynamic leadership. 

But the recent changes at the top 
of the sector's professional and 
political organisations suggest to me 
that that there may be a power 
vacuum there. 

We need somebody to cut 
through all the rubbish and get hold 
of this profession to take it forwards, 
but I don't see anybody on the 
horizon to do it. And this worries 
me at a time of unprecedented 
change that will see us needing 
management by a proactive, strong 
and unified leadership. 

The changes at the RPSCB in 
Lambeth will mean it could take the 
professional leadership body some 
time to develop and it may be 12 
months before we really know how 
things are going to pan out there. 

And the devolution of the global 
sum to PCTs may marginalise PSNC 
to some extent. I am a great admirer 
of Sue Sharpe and her team but I just 
cannot see how they can possibly 
manage 150 different PCTs 
effectively - even more so given the 
variable quality of our LPCs. 

The NPA now needs to appoint a 
new chief executive, though, and this 
could be the person that is vital to 
the future development of 
community pharmacy. I urge the 
association's appointment board to 
think long and hard about this for I 

■'■'■■';•: l! ' '■■> i in he 
the sector's 
suggest to me a 
power vacuum" 


believe that the NPA can become 
the organisation that brings all of 
the bodies representing the sector 
together - splinter groups and all. 

The NPA chief executive needs 
to be a business leader and a 
troubleshooter and the role of the 
association should be that of 

leadership. In my 42 years in 
pharmacy I have seen movement to 
unity but the old turf wars have 
always prevailed and nothing has 
happened. But now things are very 
different, and this is why I see the 
parallel with politics. The old 
loyalties and adversarial politics 
must become a thing of the past. 

The NHS cake will shrink and 
strong leadership must ensure that 
we are sitting at the table and not 
underneath picking up the scraps left 
by others. We've just pootled along 
for years with all the divisions in the 
sector but we need to become 
leaner and meaner and demonstrate 
a really strong united front to the 
Department of Health. 

The fact that pharmacy has saved 
the NHS £1.8bn in five years must 
put us in a strong position for further 
investment - but this will be hard 
won. The pharmacy bodies should 
be thinking about getting together. 

The Conservative-Lib Dem 
coalition is committed to the 
reduction of bureaucracy. We must 
ensure that existing relationships 
are strengthened and new ones 
established as quickly as possible - 
cost-saving and not pharmacy will 
be at the top of the agenda. We've 
got to go for it or I can see us being 

We have a great future in 
community pharmacy - five million 
visits a day and we are highly 
respected professionals. But we 
will have to fight for it. 

Good luck! 

Your action plan 
from Mike Smith 

MPs: Remind them about the 
APPC vision for pharmacy left 
behind by former chairman 
Howard Stoate. 

Local pharmaceutical 
committees: The global sum has 
been devolved and I can see 
some of the money just 
disappearing when the savage 
cuts hit the NHS. Talk to LPCs 
about Pharmaceutical Needs 
Assessments because we have to 
ensure those are prepared in a 
way that is factually correct or it 
could affect our livelihood. 

Primary care trusts: Talk to your 
LPC but if you're not seeing 
action, go directly to your PCT - 
it's about kicking the door down. 

Your NPA representative: If you 

share my concerns I suggest that 
you contact your NPA regional 
director now - they are there to 
represent you, and my 
experience of the NPA Board 
many years ago suggests that 
they will listen. Enough pressure 
will mean that the executive 
must also take action. 

Tell us what you think: haveyour 

What the pharmacy bodies say 

"PSNC acts as a strong, unified 
voice for pharmacy on NHS 
matters. We are proud of the 
tremendous progress pharmacy 
has made in recent years in 
developing its national influence 
and building a robust negotiating 

"It does not follow that the 
devolution of global f unding to 
PCT level will lead to the 
destruction of the national 
framework. We will continue 
to work at a national and local 

level to ensure this transition 

is managed effectively, and 

that pharmacy's capacity to 

deliver high quality NHS services 

is not impaired." 

Sue Sharpe, PSNC chief 


"The Society is the key leadership 
body representing the whole of 
pharmacy. We are working 
increasingly closely with the 
other pharmacy bodies, and 
already we are promoting the 

pharmacy agenda with 
governments from all three 

Jeremy Holmes, RPSGB chief 
executive and registrar 

"The sector does need a strong 
voice. At the NPA we have 
brought somebody in specifically 
to do that job, but the NPA 
belongs to its members and 
the profession needs to get 
involved too." 
Ian Facer, NPA chairman 

14 Chemist+Druggist 05.06.10 

Check out our guide to getting good professional advice 

The Finance Zone 

PART 5: Retirement planning. The earlier you 
start the better, says accountant Richard Baker 

Retirement planning is something 
most of us commit little thought or 
time to. Early in our working lives we 
have other priorities, such as getting 
on the property ladder or paying off 
student loans and, later on, sending 
our children to university or buying a 
second property. 

The purpose of this article is not 
to convince you to make pension 
contributions or to tell you what to 
invest in. A good independent 
financial adviser will help you to do 
this. But you should consider how 
you are going to fund your 
retirement, and the earlier you start 
the better. 

Of course, your personal 
circumstances will change over time 
and the plan will need to be 
revisited. Contributing monthly to a 
personal pension plan is one way of 
funding your retirement, but there 
are many other ways 

For personal pensions, basic rate 
taxpayers generally make 
contributions net of tax and the 
pension provider claims the income 
tax back. For example, if you 
contributed £80, the provider would 
claim back the income tax of £20, 
making your total contribution £100. 

Higher rate taxpayers are 
generally entitled to tax relief at 40 

Richard Baker: take advantage of tax 
relief to boost pension contributions 

per cent. Using the previous 
example, the pension provider would 
claim back £20 (20 per cent) and the 
taxpayer would claim back the other 
£20 (20 per cent) via their tax 
return. Whether the full 40 per cent 
is available will depend on how 
much your earnings are. 

There have been some changes 
recently that are worth mentioning. 
For those individuals lucky enough 
to have a relevant taxable income of 
£130,000 or more, there are now 
restrictions on higher rate tax relief 


Key points 

• Plan how you are going to 
fund your retirement as early 
as possible. 

• Revisit this plan as your 
personal circumstances 

• Pension contributions are 
entitled to variable tax relief 
depending on your taxpayer 

• There are new restrictions 
on higher rate tax relief on 
pensions contributions for 
those with a relevant taxable 
income of £130,000 or more. 

on pension contributions. This was 
brought in to prevent such 
individuals from obtaining tax relief 
at 50 per cent on their pension 
contributions. The rules surrounding 
this are very complex and it is vitally 
important you seek advice. 
Richard Baker is a partner at 
accountancy firm Horwath Clark 

Horwath Clark Whitehill 


Extracting profit from your 


The C+D Finance Zone Supported by 

Call 0800 328 7270 to talk to a NatWest 

advisor (quoting 'C+D') or to make an £^ NStWfiSt 

appointment with a NatWest pharmacy 

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• Biotene Oralbalance Saliva Replacement Gel 
- For relief of dry mouth 

• Biotene Oralbalance Moisturising Liquid 

Hygiene Products: 

• Biotene Fluoride Toothpaste 

• Biotene Moisturising Mouthwash 

The range is specially formulated for individuals experiencing dry mouth 
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05.06.10 Chemist+Druggist 15 


What do you think? 

Locum or employee, the stresses remain 


I was reading something recently about the high 
proportion of locum pharmacists working in 
community pharmacy, and that this was not 
necessarily a good thing. This short article in some 
journal - I forget which - seems to have raised the 
hackles of a number of locum pharmacists, 
including Richard who locums for me. 

While I understand some points the authors 
were trying to make, I think they should have 
approached it from another angle, asking why it 
is that so many in the profession choose this 
form of employment. 

It doesn't take much reading of C+D to get a 
feel for why pharmacists may be reluctant to 
become an employee. I can remember my many 
years working for a multiple, and at one point I 
was so much a company man that if you cut my 
head off I had the company name running down 
my middle like a stick of rock. 

What made me change and work as a locum for 
a couple of years? I began to realise that the cliche 
"Our most valuable asset is our staff" had been 
replaced with "Our most valuable asset is money," 
and staff came in at number nine - behind 
paperclips. So reading headlines such as 
"Employees not given support for stress" and 
"Pharmacists fear for job security" makes me 
wonder not why there are so many locums, but 
why there aren't more! 

Now Mrs Xrayser - being a registered pharm 
tech - has met more pharmacists than I, and is not 

backward in coming forward when it comes to 
expressing her opinion. She has worked with 
pharmacists with mental problems, others who 
wander off to do their shopping while scripts are 
waiting, others who are abusive, or lazy, or late, or 
worse, and these are both locums and employees 
- so there's nothing special about being an 
employee. And yet some people still hold a very 
negative attitude, perhaps best demonstrated by 
an area manager's description to me of locum 
pharmacists as a "corpse with a certificate". 

Richard says that being a locum gives him a 
chance to constrain the stress that he works 
under, and the C+D survey results that said 85 per 
cent of employees who reported stress and 
workplace issues received no support, along with 
the huge growth in membership for the PDA, 
certainly back up my experience of employment. 

Prospective employers should learn the lesson 
of Maslow's hierarchy of needs, which says that 
once we have the basic requirements of food, 
shelter and companionship, we need to feel good 
about ourselves. This means that a well paid 
profession - such as pharmacy - can't be engaged 
by money alone. 

In light of the 16 months since the old Society 
promised action on stress, this is a lesson that the 
PLB ignores at its peril, because it doesn't matter 
how many colourful benefits I get for £4 a week if 
it doesn't make a difference to my day job, be I 
employee or locum. 

The threat of hangs heavy over us 

We all make mistakes. Most 
community pharmacists, certainly 
those who have practised five years 
or more, tell a lie when they claim 
they've never made a dispensing 
error. Only a pharmacist knows 
that gut-wrenching feeling as it 
becomes clear a mistake has been 
made and a patient has taken the 
wrong medicines. 

Accidents happen even to the best 
and where we cannot undo what is 
done, we can - as well as the 
apology and the compensation - 
learn from our mistakes so that it is 
not repeated. This makes good 
business sense and is core to total 
quality management. 

Since April 1, 2009, it has been a 
requirement that community 
pharmacists, in common with CPs 
and dentists, report any serious 
adverse incidents (SAI) to the health 
and social care board (HSCB). 
Whereas the scope of what 
constitutes an SAI is wide ranging 
and includes loss of patient data, for 

example, by far the most likely SAI 
to occur in a community pharmacy 
is a dispensing error. 

For some years now I have used 
an error reporting system where all 
staff record, anonymously if they 
wish, any incident that occurs from 
near misses to very serious events 
such as where a patient got the 
wrong medicine, took it and suffered 
side effects. 

Once staff got comfortable 
reporting in the error log, the system 
became an invaluable tool for 
improving our overall quality. Each 
reported incident is assessed and 
from this we might do nothing, we 
might introduce new ways of 
working or we might get some 
additional training. 

So, in theory, I am a strong 
supporter of the requirement for 
pharmacies to report SAIs to the 
HSCB. Good intelligence of what is 
going wrong in a pharmacy 
elsewhere allows me to take steps to 
stop it recurring in my pharmacies. 

But this scheme faces a major 
barrier: a dispensing error remains a 
criminal offence and once reported 
to the HSCB it will end up with the 
DHSSPS. There seems little latitude 
there in dealing with such 
revelations, therefore it is likely that, 
since a criminal offence has been 
committed, a case file will be passed 
to the Public Prosecution Service. 

It will be up to them to decide if: 
one, it can secure a conviction in 
the courts and two, a conviction is 
in the public interest. On point one 
the defendant, by his reporting, has 
just pleaded guilty to an offence. 
Whether a conviction is in the public 
interest then becomes the main test. 
I am unhappy that pharmacists will 
be exposed in this way and I am sure 
that some may avoid reporting SAIs 
which, if uncovered at a later date, 
will attract an even heavier penalty. 

We need to be treated in the same 
ways as doctors and dentists. 
Terry Maguire is a community 
pharmacist in Northern Ireland 


16 < he 05.06.10 





17 Blood tests: pt 1 ^ 19 Arthritis meds P 20 Eye and earcare r 24 New Nice rules ^ 26 Time planning 

Your weekly CPD revision guide 

Interpreting blood test results (pt 1 ) 

How to use blood test results to support disease management 

Russell Greene MRPharmS 

Supported by 


The main reason for doing investigations is to aid 
diagnosis. Sometimes this can be definitive, such 
as a high blood glucose or thyroxine, or merely 
supportive, as with blood gases. Other important 
rationales for investigations are monitoring 
disease (eg creatinine in renal impairment), 
screening (eg cholesterol) and drug monitoring 
(eg adverse effects or therapeutic levels). 

Giving patients their results 

Patients may ask for guidance on both the 
purpose and the interpretation of tests ordered by 
other health professionals. The pharmacist should 
be cautious, however, because of the variety of 
different indications and the detailed interpretation. 

Unless you have full access to the patient's 
medical history, comments should be couched in 
general terms, with the recommendation to 
discuss the results with the healthcare worker who 
ordered the test. 

In most cases the report will cite the level found 
and the expected ('reference') range. This is the 
range found by that laboratory, using their 
particular method, in the majority (more than 95 
per cent) of the population they normally sample, 
and which is assumed to represent the limits in 
disease-free individuals. 

It must always be remembered that any 
biological measurement varies within a 
population (eg blood pressure is rarely exactly 
120/80 in every healthy individual); for this 
reason the expression 'normal values' is usually 
avoided. Moreover, for any individual, 
measurements vary at different times - blood 
pressure varies with exertion, blood glucose 
following meals, and Cortisol with time of day. This 
is why test conditions must be controlled and/or 
reported, and also the reason fasting is specified 
for many blood tests. 

Results near but outside these limits must be 
regarded with care, as the patient could be a 
perfectly healthy 'outlier'. A repeat test might be in 
order, or other evidence of illness sought. Further, 
the importance of the extent of permissible 
variation varies greatly for different tests. Quite 
small rises in potassium level, for example, could 
be acutely dangerous to the heart; conversely, 
creatinine levels may be twice normal without 
immediate ill effect (and may be greater than five 
times normal in a renal patient). 

Finally, using a battery of screening tests 
increases the likelihood that one result will by 
chance be outside the reference range but not 
represent any real problem. 

Blood tests 

Blood presents the most easily accessible and 
most informative window on the internal 
condition of the body. Many natural processes are 
controlled or supplied by blood-borne substances 
(eg nutrients, gases, mediators), and the products 
or agents of pathological processes are usually 
blood-borne. Hence blood tests are the most 
common and often the most useful initial 

The terms 'serum level' and 'plasma level' refer 
to which particular fraction of the blood is tested 
or reported, but for our purposes are usually 
interchangeable with blood level. 

These two articles will approach testing by 
discussing the tests most frequently used in 
common diseases, and what results outside the 
reference range might signify. A list of tests suitable 
for various diseases is in Table 1 on p18, and a table 
of reference ranges for these tests will be online 
next week in the full version of part 2 in this series 

What follows is necessarily an overview; for 
more detail, see the list of further reading available 
online at 

Anaemia is common and it is frequently but 
incorrectly assumed to mean a low red blood cell 
(RBC) count. However, the definition of anaemia 
rests solely on a low haemoglobin level: the lower 
limit is about 1 1g/dl (female) or 12g/dl (male). 
Mild anaemia would be 1 to 2g below this, and 
very serious anaemia less than 6g/dl. If RBCs are 
each deficient in haemoglobin (mean corpuscular 
haemoglobin - MCH), the RBC count itself may be 
near normal even though haemoglobin is reduced, 
so this is still anaemia. Conversely, extra large 
RBCs (macrocytes) in pernicious anaemia may 
initially compensate for a reduced corpuscular 
number or mean corpuscular haemoglobin 
concentration (MCHC). 

Anaemia is frequently but by no means always 
due to iron deficiency. The cause of the anaemia, 
knowledge of which is essential for rational 
treatment, is obtained only by measuring the size, 
shape, number and haemoglobin content of RBCs. 
Other important information is obtained by 
measuring folate, B 12 , and parameters of iron such 
as transferrin and ferritin. 

In some forms of anaemia, especially when due 
to acute blood loss, the proportion of immature 
RBCs (reticulocytes, normally about 1 per cent) in 
the blood rises as RBC production in the bone 
marrow increases to replace the losses. Although 

05.06.10 17 






■T 18 Blood tests: pt 1 ^ 19 Arthritis meds ^ 20 Eye and earcare ^ 24 New Nice rules ^ 26 Time planning 


Table 1 Disease state and 
relevant blood tests 

Disease state/ 
body system 



Haemoglobin (Hb); 
folate; B 12 

Red blood cell (number, 
Hb content, size); 


White blood cell (number), 
erythrocyte sedimentation 


White blood cell (subtype, 


CD4 white cells 


Platelet count, 
prothrombin time, 
international normalised 
ratio (INR) 

Renal disease 

Creatinine level; creatinine 
clearance; urea 


Na, K, Mg, chloride, 


pH, bicarbonate 


o 2l co 2 

Liver disease 

Enzymes: AST, ALT, ALP, 
GGT; albumin; 
prothrombin time 

Biliary disease 


Cardiac disease 

Creatine kinase, AST, 
lactate dehydrogenase 
(LDH), troponin (Ml); brain 
natriuretic peptide (heart 
failure), cholesterol 


Glucose, glycated 
haemoglobin (HbAlc), 
C-peptide (diabetes) 
Thyroid stimulating 
hormone (TSH), free 
thyroxine (FT4) 
Corticosteroids, sex 


ALP, calcium, phosphate, 
parathyroid hormone 


Creatine kinase 


Urate (uric acid) 

Abbreviations ALP - alkaline phosphatase; ALT - 
alanine aminotransferase; AST - aspartate amino- 
transferase; GGT- gamma-glutamyl transferase 

this will not occur in anaemias due to chronic 
deficiencies, eg of iron or folate, a rise in 
reticulocyte count can be used as an index of the 
patient's response to iron therapy. 

White cells (WBC) are a diverse group, but 
generally their function is to respond to external 
attack by initiating inflammation and/or an 
immune response. Therefore any general rise in 
WBC count (leucocytosis) implies infection or an 
inflammatory state. A raised neutrophil number is 
a sensitive indication of the latter, while 
lymphocyte numbers generally rise in response to 
microbial infection. In leukaemia, the WBC count 
may be greatly elevated but the cells are effete. 

Allergy increases particularly the eosinophil 
count. Conversely, damage to the bone marrow 
(eg cytotoxic and some immunosuppressant 
drugs) is indicated by a fall in total WBC count 
(neutropenia, leucopenia). 

Bone marrow depression and certain drugs (eg 
carbamazepine, ACE inhibitors) can also reduce the 
platelet count (thrombocytopenia) causing 
bruising and bleeding. Note, however, that aspirin 
and other antiplatelet agents do not reduce 
platelet count. A platelet excess (thrombocytosis) 
is far rarer. 

During inflammation, concentrations of 
inflammatory mediators in the blood increase, 
especially macromolecules like antibodies and 
acute phase proteins. These tend to bind to and 
cross-link red cells, causing them to clump, and in a 
stationary specimen of (anticoagulated) blood this 
increases the rate at which red cells sediment. This 
is the erythrocyte sedimentation rate (ESR), 
measured in mm/hour as anticoagulated blood 
settles in a test tube and a depth of clear 
supernatant fluid appears. It is a useful although 
only approximate measure of the degree of 
inflammation. For example, ESR will be raised 
during a rheumatoid arthritis flare-up, but it will 
fall back to normal once the attack subsides or 
is treated. 

Urea and electrolytes 

Usually known by the abbreviation U&Es, this is 
the traditional term used broadly for tests of renal 
function and fluid and electrolyte balance, 
although other abnormalities are also covered. 
Blood urea itself is not a helpful measure of renal 
function because many other factors can affect it. 
However, it is a useful index of hydration as low 
levels indicate haemodilution or overhydration, 
while high levels indicate dehydration. Sodium 
levels can also indicate the level of hydration, 
but because many factors affect sodium, 
interpretation must consider other tests and 

Creatinine level is the best general index of renal 
function as it is directly correlated with renal 
filtration, and allows the glomerular filtration rate 
(GFR) to be calculated. This is one measure that 
can reach high levels without apparent acute 
effect, because renal function can deteriorate 

markedly before symptoms appear. Thus, although 
the usual creatinine level is about 100mmol/L, it 
can rise to between 500 to 1,000mmol/L in severe 
renal impairment. 

The commonest causes of potassium imbalance 
are dietary and drug-induced. Because muscle 
function, especially the heart, is critically dependent 
on the plasma potassium level staying within the 
narrow limits of 3.5 to 5mmol/L, the body strives 
to maintain this. A low level (hypokalaemia) is 
commonly caused by dietary insufficiency 
(especially inadequate fresh fruit and vegetables) 
or by thiazide or loop diuretics. Among other 
problems, hypokalaemia reduces the threshold for 
digoxin toxicity. High levels (hyperkalaemia) can 
be induced by unmonitored potassium-sparing 
diuretic therapy or ACE inhibitors/angiotensin II 
receptor antagonists, and especially combinations 
of these. Potassium supplements are now rarely 
used, but were a problem in the past, and even 
excessive use of potassium citrate mixture has 
been recorded as a cause of hyperkalaemia, which 
can cause life-threatening arrhythmias. 

Acid-base imbalance can have many causes. 
It is indicated by blood pH, but the possible cause 
is narrowed down by also considering the 
bicarbonate and chloride levels. Acid-base 
imbalance is linked with potassium imbalance, eg 
acidosis can cause hyperkalaemia and vice versa, 
so the two measurements should always be 
considered together. 

Cardiorespiratory function 

One of the main purposes of the cardiorespiratory 
system is to maintain oxygen delivery to the 
tissues and remove carbon dioxide. Reduced 
arterial oxygen partial pressure suggests either 
that the heart is not pumping blood adequately to 
the lungs or that the lungs are not oxygenating 
properly. At the same time carbon dioxide levels 
would rise, and this would lower pH (acidosis). 

Although acidosis can have other causes, this is 
the simplest form and one of the most common. 
Known as respiratory acidosis, it occurs when lungs 
are not clearing carbon dioxide adequately and, 
again, this may be pulmonary or cardiac in origin. 

Obviously other tests would be needed to 
resolve these matters. For example, heart failure 
patients would display cyanosis owing to high C0 2 
levels, but so would COPD patients. However, in 
the former there would probably be peripheral or 
pulmonary oedema, and in the latter poor lung 
function tests (eg FEV^. 
Dr Russell Greene MRPharmS, is a 
pharmaceutical writer and consultant 
Further reading is available in the full version of 
this article online at www.chemistanddruggist. and in the CPD on p19. 

Download a CPD log sheet that helps you 
complete your CPD entry when you 
successfully complete the 5 Minute Test for 
this Update article online (p19). 


Part two describes the blood 
investigations used to diagnose 
and monitor specific diseases 

18 Chemist Druggist 05.06.10 

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Interpreting blood test results 

Registering for Update 2010 costs £37.60 (inc VAT) and can be done easily 
at or by calling 0207 921 8425. 

Signing up also ensures that C+D's weekly Update article is delivered 
directly to your inbox free every week with C+D's email newsletter. 

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the 5 Minute Test online. 

Besides haemoglobin, what other blood parameters 
should be measured when testing for anaemia? What 
does a raised eosinophil count indicate? Why are 
creatinine levels measured? What are the causes of 
potassium imbalance? 

This article discusses the blood tests most frequently 
carried out in common diseases and the interpretation of 
the results. It includes information about tests involving 
blood cells (anaemia and bone marrow depression), urea 
and electrolytes, and blood gases. 

• Find out more about the different types of anaemia 
and the blood tests used for diagnosis on the Lab Tests 
Online website at 

Update your knowledge of the full blood count 
test on the Lab Tests Online website at 

Find out more about blood tests in kidney disease by 
reading information on the Edinburgh Renal Unit website 

Read more about blood tests for potassium and 
calcium on the Lab Tests Online website at and 

Are you now familiar with the tests involving blood cells, 
urea and electrolytes, blood gases and the conditions 
they help diagnose? Could you advise patients about the 
MttHilllMflHI interpretation and limitations of the results? 

Practical Approach 

Complementary medicines for arthritis 

David Spencer, pharmacist at the 
Jpdate Pharmacy, is visiting his 
Blderly uncle Morris. 

During their conversation Morris 
>ays: "David, you're a chemist so you 
mow about these things. What do 
/ou think about this glucosamine 
and chondroitin for arthritis? I keep 
seeing it advertised in the newspaper 
and wonder whether it's worth a try. 
And, if it's any good, could I get a 
prescription for it from my doctor?" 

"Are you taking anything for your 
arthritis at the moment?" David 
asks Morris. 

"Yes, I've got some tablets from 
the doctor. Let me show them to 
you," and Morris takes a pack of 
naproxen 250mg tablets out of a 
drawer. "They help, but it's not 
going away. I just wonder if this 
glucosamine, instead or together 
with them, might be more effective." 

David replies: "Uncle, what you've 
got is called osteoarthritis and I'm 
afraid there's no cure for that. Your 
naproxen will just help ease the pain 
and stiffness. To help me advise you, 
can you tell me if you take any other 

"Oh, quite a few," says Morris and 
takes out of the drawer packs of: 
indapamide 2.5mg, labelled one in 
the morning; isosorbide mononitrate 
m/r 60mg, 1 om; metformin 500mg, 
1 tds; warfarin 3mg, 1 om. 

David examines them and says: 
"Well, here's my advice about 
glucosamine and chondroitin." 


1. Are glucosamine and 
chondroitin safe for Morris to 

2. Are there any general cautions 
or contraindications for 
glucosamine or chondroitin? 

3. Are they effective in treating OA? 

4. Is exercise beneficial for OA? 


1. Both glucosamine and chondroitin 
appear to be well tolerated 
generally. However, animal studies 
have raised the possibility that 
glucosamine may worsen insulin 
resistance, although so far studies in 
humans have not substantiated the 
risk. Nevertheless, Morris should 
monitor his blood sugar level 
particularly carefully if using 
glucosamine. Also glucosamine and 
chondroitin both enhance the 
anticoagulant effect of warfarin and 
concomitant use should be avoided, 
so Morris should not take them. 

2. Glucosamine is manufactured by 
processing the crushed shells of 
crustaceans and may lead to an 
allergic reaction in individuals 
allergic to seafood. 

3. As more clinical trial results have 
become available, the initially fairly 
optimistic opinion of the efficacy of 
glucosamine and chondroitin, from 
mostly small and producer- 
sponsored studies, has been 
reversed. A recent large-scale 
randomised controlled trial involving 

patients with OA of the knee 
revealed that glucosamine, 
chondroitin, or both, did not differ 
from placebo for pain relief. 1 
Another found glucosamine no 
better than placebo in reducing 
symptoms and progression of hip 
OA, while a meta-analysis 
concluded that the symptomatic 
benefit of chondroitin for this 
condition was minimal or non- 
existent. 23 Nice has suggested 
that glucosamine products should 
not be recommended for the 
treatment of OA. 
4. There is evidence that aerobic 
walking and muscle resistance 
training are beneficial for knee and 
hip OA. Manipulation and stretching 
are also helpful for hip OA. 

References are available online at 

Do you have an idea for a Practical 
Approach scenario or would you 
like to write one? Email us at: 

05.06.10 Chemist : Druggist 19 


17 Blood tests: pt 1 ^ 19 Arthritis meds 20 Eye and earcare 24 New Nice rules 26 Time planning 

CA'ft* >>■ Mf FOCUS 

Eye and earcare 

Pharmacists can capitalise on the £64 million eye and earcare market by focusing on 
education and making the most of seasonal opportunities, reports Hannah Flynn 

Eye and earcare category sales together 
are worth £64 million, according to 
data from IRI and IMS, and the eyecare 
market in particular is worth over £56m and 
showing double digit growth of nearly 14 per 
cent. Strong television campaigns for products 
including Optrex Actimist and Murine eye drops 
have driven the healthy growth in the eyecare 
sector, say the manufacturers. 

But grocery's eyecare market share is growing 
significantly faster than pharmacy's, so how can 
pharmacists ensure their customers are getting 
the best out of eye and earcare products and 
make sure they capitalise on the growth at the 
same time? 

An increase in the number of patients seeking 
advice from their pharmacists is a positive trend, 
particularly in eyecare, says Philip Lewis-Williams, 
managing director of preservative-free 
ophthalmics manufacturer Spectrum Thea. 

Mr Lewis-Williams says: "We are seeing a trend 
towards patients asking for advice before going to 
their GPs. The trend will continue for self- 
medication. I think pharmacies have an 
important part to play there and I think by 
providing more education they can increase sales 
in this area. [For example], pharmacists could 
give advice for blepharitis, which is the biggest 
cause of cancellation of cataract operations in 
the UK." 

Three tips for boosting 
eye and earcare sales 

1. "To help maximise sales and ensure the eye 
drops are used to best effect, help customers 
narrow down the decision process and select 
the relevant product by using signage, shelf 
talkers or direct assistance." 

Sally Walton, marketing manger, Murine 

2. "Make sure patients know there is a 28-day 
expiry date on their eye drops, then they will 
come back and get more." 

Alison Lyons, divisional services manager, 
Co-operative Pharmacy 

3. "You need to let your customers know 
where to find products, so signpost them with 

Adam Bishop, UK pharmacy channel team 

leader, P&C 

20 -.i 05.06.10 

Get Category Focus articles emailed to you 


Some educational tools for pharmacists 
have launched recently, including Moorfields 
Pharmaceuticals' website for the diagnosis 
and treatment of dry eye syndrome 
(www, and marketing 
manager for eye drops manufacturer Murine Sally 
Walton agrees educating customers is key to 
increasing sales. 

Ms Walton says. "Educating the customer 
about the environmental causes of dry eyes, such 
as central heating, air conditioning, computer use 
and travel, can help identify the cause of the 
common problem and identify when it is best to 
administer eye drops." 

In terms of brand vs generics, Optrex is the 

Brand Watch 

most popular eyecare brand, according to IRI, but 
in earcare, Alison Lyons, divisional services 
manager for the Co-operative Pharmacy, says 
generic olive oil and sodium bicarbonate eardrops 
are among the most frequently requested 
products by customers. 

Ms Lyons says: "There are some people referred 
to us by the nurse or CP who need to clear their 
earwax. They usually request those rather than 
knowing brands." 

Timing and placing of both eye and earcare 
products can be crucial to sales, as well. Ms 
Lyons says that placing eye drops with hayfever 
remedies during the hayfever season could 
boost sales, as could suggesting them 

Market Insight: 
Eye and earcare 

Golden Eye 

Eyecare range Golden Eye launched 
a website in April this year,, offering 
information for consumers on the 
range of drops and ointments, how 
to prevent eye infections, and FAQs. 
And there is also a section dedicated 
to trade, where training materials 
are available for downloading. 

Manufacturer Dendron says the 
Golden Eye brand has a long clinical heritage, and that its popularity can be seen through its sales. It 
is the third best-selling eyecare range in the UK, IRI data shows. 

The range includes Golden Eye Standard Ointment and Drops for minor eye infections and 
irritations including conjunctivitis, blepharitis and styes. It also includes Golden Eye Antibiotic Eye 
ointment and drops, for acute bacterial conjunctivitis. 


bright & 

UK Hsl eves 


wel & i lean 
contai t lorn 



Ceuta Healthcare has announced the 
largest ever UK press campaign for the 
Murine range of eye drops, to be run 
throughout 2010. 

The campaign has been designed to build 
the brand profile, but most significantly to 
educate people about the role of eye drops, 
according to the company. 

Figures are not yet available for the 
campaign, which will continue until the end 

of the year, but it will include the brand working with a celebrity case study and an "extensive" 
consumer print campaign, Ceuta says. 

The products in the range include Murine Bright & Moist Eyes, Murine Dry & Tired Eyes and 
Murine Wet & Clean. All three have an RRP of £3.99/15ml. 


dry & tired 

The eye and earcare sectors are collectively 
worth £64 million. 

The eyecare sector has grown significantly 
over the past year, with an almost 14 per 
cent rise year on year (IRI value sales, 52 
weeks to March 20, 2010). Pharmacy, 
including Boots and Superdrug, holds almost 
three quarters of the £56. 4m market; 
however, its grocery rivals are seeing faster 
growth of 22 per cent, compared to 11 per 
cent. IRI says the market's double digit 
growth was significantly driven by last year's 
launch of Optrex Actimist. 

The total earcare market is smaller, 
worth £7.6m (IMS, MAT December 2009), 
with 2.2 million units sold annually. It is 
predominantly made up of eardrops (84 per 
cent), worth £6.4m. 

Olive oil-containing products are showing 
strong growth of 57 per cent year on year. 

Market changes 2009-10 

Total market value 






eyecare brands 

1 3.8% 

1. Optrex 

2. Own label 

3. Golden Eye 

4. Vitaleyes 

5. Brolene 

Source: IRI value sales, 52 weeks 
to March 20, 2010 

6. Blink 

7. Murine 

8. Almus 

9. Brochlor 

10. Refresh 


m SfwiWirouj* Snuff i 


o Prevention and relief from itchy allergy eyes 

o Used at the first sign of hayfever eye symptoms, 
Optrex Allergy Eyes eye drops can help prevent 
symptoms from getting worse 

° AND once symptoms have started Optrex Allergy 
Eyes eye drops provide fast, direct relief 


Optrex Allergy Eyes eye Drops: Eye drop containing 
Sodium Cromoglicale 2.0%w/v. 
Indications: For the relief and treatment of seasonal 
allergic conjunctivitis. 

Dosage: One or two drops in each eye four times a 
day or as indicated by the doctor. 
Contraindications: Hypersensitivity to sodium 
cromoglicate, benzolkonium chloride or disodium 

Precautions: Discard ony remaining contents four 
weeks after opening the bottle. As with other 
ophthalmic solutions containing benzolkonium chloride, 
soft contact lenses should not be worn during the 
treatment penod. 

Undesirable effects. Transient stinging and burning 
may occur after instillalion, other symptoms of local 
irritation have been reported rarely. 
Legal Classification: P 

Licence Holder: Tubilux Pharma SpA, Pomezio, Italy 
Licence No: PL 17918/0005 
Price: £5.60. 


4 17 Blood tests: pt 1 ^ 19 Arthritis meds 22 Eye and earcare p 24 New Nice rules P 26 Time planning 

to customers at the point of sale. 

The sales of earcare products fluctuate slightly 
throughout the year, according to IMS data, with 
a slight dip in sales seen during the winter months 
of January to February and November to 
December 2009. 

The increasing age of the population could also 
be accountable for the rise seen in the earcare 
sector. Director of the Nash Croup Amin Bandali 
said his pharmacy surveyed its local community 
to find out what services they wanted. 

He said: "One thing people wanted 
when we asked them was a hearing service. In 
our community more than 80 per cent of the 
population is of retirement age so it was a good 
service to offer." 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on eye and earcare 

REFLECT Are my patients using OTC eye 
and earcare products 

PLAN Review my knowledge and staff 
sales protocols 

ACT Read this article, revise minor 

eye and ear ailments and 
update staff training 
if necessary 

EVALUATE Do my patients get good advice 
on minor eye and earcare 
ailments and how to self-treat? 

Case studies 



Director of the Nash Group Amin Bandali has overseen the 
development of a hearing laboratory at one of its pharmacies in 

St Albans. 

The pharmacy group joined forces with a hearing aid audiologist to start 
up the hearing laboratory, which offers free hearing tests. The service 
generates income through hearing aids and accessories sold to patients. 

Mr Bandali says: "We offer free hearing tests to the elderly and our 
audiologist fixes their hearing aids for a small fee when they come to us, 
so we offer a complete service." 

He suggests promoting any service offered through local GPs, and maintaining a strong relationship 
with them. He says: "We sent posters, brochures and leaflets to our local CP surgery and they are very 
supportive and let their patients know about us." 



Pharmacy manager Phil Wilkes shares his tips for boosting eyecare 


"One of the biggest changes in recent years has been the availability of 
chloramphenicol in the pharmacy. Obviously we can't keep it in the 
pharmacy as it has to go in the dispensary fridge, but since we have had 
signs out in the pharmacy, customers have known it is there. That is 
something we sell well. 

"We have increased sales by promoting products when they were the 
focus of television campaigns, and also by using seasonal promotions like putting eye drops with 
hayfever remedies. 

"When I first saw Optrex Actimist spray I thought it would never sell for £15 a bottle, but it did when 
we promoted it around what was being advertised on television." 



5 O 

1 3 

Dry eyes solutions from Moorfields Pharmaceuticals 

Available on prescription 



22 Chemist-Druggist 05.06.10 

More Category Focus articles 


Product Watch 

Systane Lubricating 
Eye Drops 


Alcon Laboratories 

Medical device; 
available on 
For: Dry eye relief 
Active ingredient: 
glycol 400 0.4 per 
cent; propylene 
glycol 0.3 per cent 

USP: Upon contact with the eye forms a gel- 
like barrier, according to the manfacturer. 
Tel: 0800 092 4567 

Format/pack size: 10ml bottle; 28 x 0.8ml 
single dose vials 

Pip code: 303-8965; 041-4052 

RRP: £6.85; £6.85 




Manufacturer: GSK 


Consumer Healthcare 
Classification: P 




For: Treatment of 

Medical device; 

H^piomclloic eye drop: 3% BP « 

superficial infections of 

available on 

the external auditory 



canal, such as otitis 

For: Relief of mild to 

externa (swimmer's ear) 

moderate dry eyes 
Active ingredients: 

Active ingredient: 

glacial acetic acid 

Hypromellose 0.3 per cent 

2 per cent 

What's new? 

USP: EarCalm is the 

In December, Moorfields launched a 

only branded OTC 

dedicated website for pharmacists on the 

product for treating 

diagnosis and treatment of dry eye syndrome. 

outer ear infections, 

according to the 

Tel: 0207 684 9090 



Tel: 01202 780558 

Format/pack size: 30 x 0.4ml 

Pip code: 349-0174 

Format/pack size: 5ml spray bottle 

Pip code: 264-8996 

RRP: £6.45g 

Care Olive Oil Eardrops 

Manufacturer: Thornton & Ross 

Classification: Medical device; available on prescription 
For: Softening and removal of earwax 
Active ingredients: 
Medicinal grade 
olive oil 
What's new? 
Launched last year, 
www. care- 
Tel: 01484 842217 

Format/pack size: 10ml bottle 

Pip code: 346-7768 

RRP: £2.55 


otex > 

Manufacturer: Dendron |g 
Classification: P |£ 
For: Earwax softening 
Active ingredients: Urea 
hydrogen peroxide 5 per cent 

What's new? Otex has a 39 per cent share of the earcare market (IMS, 
September 2009) and will be supported by TV activity throughout the 
year, the manufacturer says. 
Tel: 01923 205706 

Nutritional Support 
for Healthy Eyes 






For further information please contact us: 

Tel: 020 8426 3400 


05.06.10 Chemist Druggist 21 

Format/pack size: 8ml drops; 10ml 'Express' drops; 10ml 'Express 
combi pack' with bulb syringe 

Pip code: 205-2330; 334-5501; 345-3305 

RRP: £4.65; £4.95; £7.95 

17 Blood tests: pt 1 'H 19 Arthritis meds 20 Eye and earcare W 24 New Nice rules f 26 Time planning 


Childhood constipation 

Following the publication by Nice of the first national guidelines for childhood 
constipation. Gavin Atkin explains what you need to know 

Constipation in children is rarely sinister, but sufferers can 
experience social, psychological and educational problems that 
often require prolonged support. Early identification and 
treatment improves outcomes and reduces the demand on 
health services. 

GPs diagnose idiopathic constipation by excluding underlying 
causes, and by carrying out a physical examination to establish 
whether the child has impacted faeces in his or her colon. 
This must be cleared before the child can be prescribed 
maintenance therapy. 

Although dietary intervention alone is not recommended as a 
first-line treatment, parents should be given advice on diet, 
fluid intake and exercise appropriate to the child's age and 
development. Parents should adopt a positive approach and 
encourage their child to take time to go to the toilet. This can be 
done for example by scheduling times to do so, recording the 
child's movements in a diary, and rewarding the child 
appropriately when they use the toilet. A cows' milk exclusion 
diet should only be started on the advice of a specialist. 

A stimulant laxative should be added if polyethylene glycol 
3350 with electrolytes does not lead to disimpaction after two 
weeks. Parents should be told the treatment can initially 
increase symptoms of soiling and abdominal pain. A stimulant 
laxative, on its own or in combination with an osmotic laxative 
such as lactulose, may be used if the initial treatment is not 
tolerated. See the Nice guidance for full doses. 

Maintenance therapy should be started using polyethylene 
glycol 3350 with electrolytes as soon as the patient's bowel is 
no longer impacted; the suggested dose is about half the dose 
used in disimpaction, and is likely to be adjusted according to 
the symptoms and response. A stimulant laxative may be 
added if the initial treatment is not effective, and lactulose or 
docusate may be used if stools are hard. 

Once the impacted material has been cleared, maintenance 
treatment using laxatives should be prescribed to help the child 
establish a regular bowel habit. This may take months, and 
during this time the child should be examined frequently to 
make sure faecal impaction does not become re-established. 

Appropriate laxative doses are essential to relieve faecal 
impaction, says Nice. Many of the doses given in the guidelines 
are not as given in the British National Formulary for Children 
and/or outside the product licence, and informed consent must 
therefore be obtained. 

During treatment for faecal impaction the child must be 
followed up within one week to ensure the treatment is 
working. Nice recommends paediatric formula polyethylene 
glycol 3350 with electrolytes (polyethylene glycol 3350 
6.563g; sodium bicarbonate 89.3mg; sodium chloride 175. 4mg; 
potassium chloride 25.1mg) as first-line treatment. The sachets 
can be mixed with a cold drink. 

For disimpaction in children under one the dose should be half 
to one sachet daily; children aged one to five should receive two 
sachets on the first day, then four sachets daily for two days, 
then six sachets daily for two days, then eight daily; and 
children aged five to 12 should receive four sachets on the first 
day, increased in steps of two sachets daily to a maximum of 12 
daily. The Nice guidance includes separate dosing instructions 
for the adult formula treatment and for other laxatives. 

Medication at the maintenance dose should be continued for 
several weeks after regular bowel habit has become 
established. Treatment should not be stopped abruptly, and the 
dose should be gradually reduced over a period of months in 
response to stool consistency and frequency. Some patients 
may require laxative therapy for several years or longer. 

For references go to: 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on childhood constipation 

REFLECT Is my knowledge of treating childhood 
constipation current? 


Read about the latest guidelines 

Read the C+D guide and Nice's new guidance 

EVALUATE Am I confident in advising on childhood 

24 Chen ruggist 05.06.10 


over 14,720 applications since launch 


0207 921 8123 

Booking and copy date Contact: Andrew Walker Chemist+Druggist 

12 noon Monday prior Tel: 0207 921 8123 Ludgate House 

to Saturday publication Fax: 0207 921 8132 245 Blackfriars Road 

subject to availability London SE1 9UY 



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Company car and company mobile provided Full time 37.5 hrs pw 

Job 1: North East Job 2: Manchester/Liverpool/Southport 

Reporting directly to the Commercial Services Manager, you will have an 
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The role involves building and developing established relationships with 
branch staff to facilitate the delivery of services and support and coach the 
staff with their individual reguirements. 

The role will be field based and you must be prepared to travel inline with 
company needs. Monthly meetings will be held in a central location and some 
overnight stays may be required. 

You should be an excellent communicator and have experience of building and 
developing business relationships. Results focused and have the ability to 
motivate and influence staff to deliver services at branch level. Team work and 
people management skills are key along with the ability to adapt to meet 
business needs. 

To apply for this position please forward a covering letter and CV to: 
Nicola Dyson, Commercial Services Manager, Rowlands Pharmacy Head 
Office, Rivington Road, Whitehouse Industrial Estate, Preston Brook, 
Runcorn, Cheshire WA7 3DJ. Or email: 

Closing Date: Monday 21 June 2010. p» 




We are looking for an enthusiastic full time dispenser/ 
dispensing assistant to join our team in this busy, friendly 
health centre pharmacy. Training will be provided if needed. 
The ideal candidate will be working closely with the complete 
health care team in order to deliver NHS service. 

Please apply with a CV. to Beran Patel at 020 8689 7127 
( b e r a n p a t e II @ h o t m a i I . c o . u Ik ) 
Brigstock Pharmacy 
141 Brigstock Road 
Thornton Heath 
Surrey CR7 7JN 


Enthusiastic Pharmacists required to manage and provide the full range 
of services in our established and well supported branches within the 
Oxfordshire and Bedfordshire areas. 
Send your CV by email: 
or call on. 01582 560393 



jlAa.L"Ln3.(:V L co,L[ 






Pharmacy Manager 
Longlevens, GIoucs 

(^excellent + benefits + relocation)Fantastic 
opportunities at heart of Community pharmacy. 
Email your CV to 

or call on 02476 432983 





17 Blood tests: pt 1 ^ 19 Arthritis meds 4 20 Eye and earcare si 24 New Nice rules 

26 Time planning 

my time 

Kelly Mooney (pictured) of 
Lloydspharmacy's Irvine, Ayrshire 
branch shares her top tips for 
time management with Jennifer 

1. Prioritise 

"I took a sample week and every 
single day I wrote down everything I 
did. At the end of the week, I 
skimmed out all of the tasks I didn't 
need to do. Some of them went in 
the bin, others I delegated to other 
people, so that I was just doing the 
tasks that only I was qualified to do. 
I managed to free up half an hour 
each Friday to sit down with my 
pre-reg student." 

"When we took on a second prison 
contract at the branch there was 
quite a lot of extra work to fit in, so 
I started a weekly planner board - 
like a big jigsaw puzzle. I use it to 
work out who's the best person to 
do each job." 

Ms Mooney has found that 
challenging established processes in 
the pharmacy - mostly simple 
scheduling changes such as the time 
prescriptions are picked up from the 
surgery - has created better 
workflow. Consider why you're doing 
things, who's best-placed to do them 
and when, she advises. 

4.. Communicate 

As well as charts to keep everybody 
updated on how major tasks are 
progressing, Ms Mooney holds 
regular team meetings to discuss 
what's working and how things 
can be improved. "We'll try 
something for a couple of weeks 
and then discuss whether or not it 
works for everyone," she says, "so 
we're continually trying to 
streamline things." 


Beat the clock 

A few time management skills can make a big difference in easing 
the pressures of the day, writes Chris Chapman 

If there's one thing most 
pharmacists want, it's more 
time. Life in the dispensary 
means there often seems to be 
too much to cram in - be it 
prescriptions, phone calls, sourcing 
stock or hitting MUR targets. 

There is no easy solution to a busy 
workload. However, investing a little 
time in a few time management 
tricks can make a huge difference in 
keeping your head above water. 

Planning ahead 

Good organisation is all about 
planning ahead. Consider what you 
need to do: what is your end goal? 
Once you've established your aim, 
think about what you need to do to 
achieve this Map out the steps in 
order, and break up the target into 
smaller, manageable, chunks. For 
example, if you're trying to hit 400 
MURs, start small - set yourself a 
target of 10, then 50, then 100. 
Make sure the goal is something you 
can measure at the end, so you can 
see how you're doing. 

The next step is to apply a 
timeframe for achieving each goal. 
It's important that you make this 
realistic - say, 10 MURs in a week 
and a half, and 100 within three 
months. Now, as long as you check 
your list and see how you're doing, 
you shouldn't find yourself in a 
desperate scramble to complete a 
project all in one go. When you 
complete a task, cross it off the list. 

And planning your time isn't just 
useful for achieving long-term aims. 
Try mapping out the tasks you need 
to do on a weekly chart, making sure 
that you've assigned a reasonable 
amount of time for each activity. 
This will make sure you keep smaller 
jobs on your radar, and that you 
don't get swamped by taking on too 
many jobs in too small a timeframe. 

Prioritising tasks 

But what if you've just got too much 
to do? You need to prioritise. But are 
you prioritising the right things? It's 
easy to put off a hard task in favour 
of something that's not important 
but far more enjoyable, leaving more 
pressing jobs to the last minute. 
Fortunately, there are a couple of 

So much to do, so little time: could better time management free you up? 

tricks you can use to see what's 
important and what you can do 
without. One of the most popular is 
the Eisenhower method - named 
after the US president and general 
who is said to have used it. 

Draw a graph, with 'importance' 
on the x axis and 'urgency' on 
the y axis. Turn the graph into four 
equal boxes - important/urgent, 
important/not urgent, not 
important/urgent, and not 
important/not urgent. 

Now write a list of all the things 
you do on a typical day. Try to cover 
everything, from answering the phone 
and rearranging shelves to checking 
prescriptions and making cups of tea. 

Assign each task a number from 
one to 10 in terms of importance. 
Then go through the tasks again, 
assigning it a number from one to 10 
in terms of urgency. Now, map these 
into the boxes you've created. 

You should have a couple of tasks 
in the important/urgent box - such 
as dispensing prescriptions. These 
are the tasks you need to do as a 
priority. And again, once the task is 

completed, cross it off your list. 

There will also be a cluster in the 
important/not urgent box, such as 
hitting your MUR target or sending a 
report. You don't need to do these 
immediately, so concentrate on 
getting the important/urgent tasks 
out of the way. Break the important/ 
not urgent tasks up into manageable 
and measurable stages as before. 

Tasks in the not important/urgent 
box need dealing with quickly - such 
as answering the phone, or checking 
the stock order. But ask yourself if 
it's you who needs to do it; maybe it 
can be delegated? 

For tasks that are not important 
or urgent, consider dropping them 
altogether, or using them to reward 
yourself for getting an important 
taskoutofthe way if you enjoy them 

In a nutshell, time management is 
about planning ahead and prioritising. 
There is no foolproof method - 
problems are always going to crop 
up that will demand your attention. 
But just by putting a few tactics into 
practice, you can make a real 
difference to staying on track. 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on time management 

REFLECT Do I manage my time effectively? 

PLAN Consider whether the methods in this article could help me 

better manage my time 
ACT Implement methods 

EVALUATE Do I feel more in control of my workload and do I have 
more time to spend on patient care? 

26 Chemist+Druggist 05.06.10 

Having trouble finding the right staff? CLASSIFIED 

0207 921 8123 

Contact: Andrew Walker 

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Springboard is a pre-registration programme offered by Medway School 
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The Springboard pre-registration training programme consists of eight 
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05.06.10 Chemist-Druggist 27 


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05.06.10 29 


Got a story for Postscript? 

appetite," answered 
the invalid. "Mercy!" 
soliloquised the doctor, 
"I hope no poor man 
has found it." 

Dear Sir, 

Recently, a colleague shared a few splendid 
examples of medical humour, which I feel 

compelled to deliver to a wider audience. 


"Do you believe in ghosts?" asked a lady of 
one of our celebrated surgeons. "I should be 
sorry to believe in them, madam," was the 
reply. "Sorry! And why?" asked the lady. 
"Because if I did," rejoined the surgeon, "I 
should never dare to practise my profession." 

Our friend J. is the picture of health, but he 
is somewhat nervous when his liver gets at all 
out of sorts. He went to consult a physician. 
"What do you chiefly complain of?" asked Mr 
D. "I have lost my appetite," answered the 
invalid, in a voice which almost made the 
windows rattle. "Mercy!" soliloquised the 
doctor; "I hope no poor man has found it." 


Chambers' Journal tells the story of a 
student who underwent an examination in 
medical jurisprudence. "Pray sir," said the 
examiner, "what is a poisonous dose of 
prussic acid?" The student replied with 
promptitude, "Half an ounce, sir!" Horrified 
at the ignorance of the candidate, the 
examiner exclaimed, "Half an ounce! Why, sir, 
that would poison a community, not to speak 
of an individual!" "Well sir," replied the 
student, "I only thought I'd be on the safe side 
when you asked a poisonous dose!" 

It was no laughing matter (despite best 
attempts) with this column of medical 
jokes, published in C+D in 1883. 
Fortunately medical humour has 
moved on in the intervening 127 years. 
Do you know a good - and clean - 
medical joke? The Victorian Pharmacist 
clearly doesn't. Share yours at 

A star pupil 

Middlesbrough pharmacist Michael Maguire 
(pictured above) went back to school last month 
when he scooped an Alumni Enterprise Award 
from the University of Sunderland. 

Mr Maguire, who graduated from the uni in 
1988, received the accolade for his work in 
delivering health initiatives to his local 
community, including everything from smoking 
cessation and weight management services to 
chiropody and acupuncture. 

If running his Marton Pharmacy wasn't enough, 
Mr Maguire has also founded the groups 'Love 

Middlesbrough' and 'Love Health', aiming to boost 
the negative image of the Tees town and improve 
public health in the area. 

Mr Maguire described winning the award from 
his old university as a "real honour". "It motivates 
me to push the boundaries of pharmacy even 
further," he added. 

Mr Maguire adds the gong to a trophy cabinet 
that also includes a C+D Award, after he won the 
Community Pharmacist of the Year accolade at 
last year's bash. 

• Who is C+D's Community Pharmacist of the 
Year 2010? Find out in next week's C+D. 

Pop quiz 

Postscript is a bit nifty when it comes to pub 
quizzes (probably because we spend too much 
time in pubs), and happened to come across two 
trivia gems related to pharmacy last week. 

Rather than keep them to ourselves, we 
thought a challenge was in order, so get your 
brains in gear and see if you know the following: 

1. Which figure, famous for being a bit unpopular, 
is buried in the garden opposite RPSGB 
headquarters in Lambeth? 

2. What connects June 1 with the current 
pharmacy minister? 

If you need a clue, both questions have a 
maritime bent. The quiz is just for fun, and 
answers will be posted next week. If you can't 
wait, check out @CandDChris on Twitter -the 
spoilsport has already revealed the solutions. 

Z+D reader of the week 

Meet Bobby Mehta, football fan, radio DJ and pharmacy 
~~ manager for Rowlands Pharmacy's Farnnam branch 

If you were not a pharmacist, what would you 

be? That's interesting. I work part-time as a radio 
DJ, and do Sunrise radio from 7-9pm on Saturdays 
and Sundays. So I think I'd be a full-time DJ. 

What's the most memorable thing you were 
taught at university? How to make copper 
sulphate suppositories. I've never had to do it! 
What was the point of learning that? 

What's the strangest request you've ever had? 
Someone came in and asked if we sold cigarettes. 
We just looked at them as if they were mad. 

Would you recommend pharmacy as a career? 

Yeah, there's a lot happening. It's not just a single 
facet profession - there's something for everyone. 

Do you have a hidden talent? I'm a qualified FA 

football coach. I still play - I've got a slipped disc 
and have had three knee operations, but I can still 
outrun 18-year-olds. 

If you had a time machine, where would you 

go? To the 2005 Champions League Final, when 
Liverpool beat AC Milan [on penalties after coming 
back to level the match at 3-3]. It was an 
incredible match, I'd love to have been there. Can 
you imagine how many people left at half time? 

What question should we ask the next 
person? If you could offer any new service in your 
pharmacy, what would it be? 

Calling all pharmacists and technicians. We 
want you to be our reader of the week. Email 
us at 

30 C hemist+Druggist 05.06.10 

Two new courses 
for pharmacy staff 
from C+D 

New starter? Want to get them off to a good start but 
without having to put them onto a medicines counter 
assistant's course straight away? 

Counterstart is an induction course for new pharmacy counter staff that will equip 
them with the basic knowledge required to work in a pharmacy safely 

The course covers: 

• My pharmacy and the pharmacy team 
® Customer service 

• Privacy supported by 

• Safety at work 

• Selling medicines safely Reckitt 
Dealing with prescriptions. Betickiser 


Induciion couise for ph 


For just £15 (ex. VAT) you can ensure your new staff have a basic training - 
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Different types of medicines 

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prefer it over Beconase® and Flixonase® 23 . Give them Nasacort and help avoid problems 
whenever hayfever's around. For more information about Nasacort Allergy, and copies 
of training materials and point-of-sale items, please contact your local Laser Healthcare 
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Contains triamcinolone acetonide 

fays where it's sprayed 

mtation: 20 mi bottle, providing 30 actuations containing 55mcg triamcinolone acetonide per 
metered dose. Indications: Treatment of the symptoms of seasonal allergic rhinitis. Dosage and 
" ' linistration: Patients aged 18 years and over: The recommended dose is 220 micrograms as 
s in each nostril once daily. Once symptoms are controlled patients can be maintained on 
ams (1 spray in each nostril once daily). The minimum effective dose should be used to 
lued control of symptoms. Medical advice should be sought if symptoms worsen or persist 
s treatment. Contraindications: Hypersensitivity to the active substance or excipients, 
the nose. Precautions and Warnings: If adrenal function may be impaired, take care 
hen transferring patients from systemic steroids. Localised infections of the nose and pharynx with 
Candida albicans has rarely occurred. Following, recent nasal surgery or recent prolonged nose bleeds 
r any other nasal problems patients should consult their doctor before use. Treatment with high doses 
nay cause adrenaj suppression Not recommended under 18 years. Not to be used for longer than 3 
bnths' without consulting a doctor. Interactions: No interactions known. Pregnancy and Lactation: 
inistered during pregnancy or lactation unless therapeutic benefits outweigh the 
oetus/baby. Adverse Reactions: The most commonly reported adverse reactions 
e' and pharyngitis. Respiratory disorders: epistaxis, nasal irritation, dry mucous 
us congestion and sneezing; rarely, nasal septal perforations. In clinical trials 
ons with the exception of epistaxis, were reported at approximately the same or 
placebo treated patients. Skin or subcutaneous disorders: rarely allergic reactions 

including rash, urticaria, pruritus and facial oedema. Systemic effects of nasal corticosteroids may 
occur, particularly when prescribed at high doses for prolonged periods. Retail Price: 30 metered 
dose bottle: £4.95 Legal Category: P. Marketing Authorisation Number: PL 04425/0605. Refer 
to Summary of Product Characteristics for full prescribing information. Further information 
is available from the Marketing Authorisation Holder: Medical Information Department, sanofi- 
aventis, One Onslow Street, Guildford, GU1 4YS. Tel. 01483 505515. Date of Revision of Prescribing 
Information: April 201 0. 

Information about adverse event reporting can be found on Adverse events should also be reported 
to the sanofi-aventis drug safety department on 01483 505515. 

References: 1. Nasacort Summary of Product Characteristics, October 2008. 2. Lumry W et al. 
A comparison of once-daily triamcinolone acetonide aqueous and twice-daily beclomethasone 
dipropionate aqueous nasal sprays in the treatment of seasonal allergic rhinitis. Allergy Asthma Proc 
2003;24(3):203-10. 3. Stokes M et al. Evaluation of patients' preferences for triamcinolone acetonide 
aqueous, fluticasone propionate, and mometasone furoate nasal sprays in patients with allergic rhinitis. 
Otolaryngol Head Neck Surg 2004; 131(3):225-231. 

PIP code 342-5501. SdDOfi QVefltiS 

ation: April 2010. GB.TRM.1 0.04.01